lesioni al polso secondo - Gianni Rigoni-Lunate Fracture Ligament Injuries-Scapho Lunate...
Transcript of lesioni al polso secondo - Gianni Rigoni-Lunate Fracture Ligament Injuries-Scapho Lunate...
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THE WRIST JOINT:THE WRIST JOINT:ATHLETIC INJURIESATHLETIC INJURIES
Gianni RigoniGianni RigoniFMH HandsurgeryFMH Handsurgery
SSMSSSMS
Wrist Wrist unityunity
““The wrist links the hand The wrist links the hand to the forearmto the forearm””
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AnatomyAnatomyBoneBone
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S
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H CTid
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IIIIIIVV
AnatomyAnatomyIntrinsicIntrinsic ligament ligament
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AnatomyAnatomyTriangularTriangular fibrocartilagefibrocartilage(TFC)(TFC)
AnatomyAnatomyVolar Volar capsularcapsular ligamentligament
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AnatomyAnatomyDorsalDorsal capsularcapsular ligamentligament
AnatomyAnatomydorsaldorsal capsularcapsular ligament ligament (extensor (extensor retinaculumretinaculum))
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Wrist injuriesWrist injuriesSprainSprain and and FractursFracturs
IndirectIndirect injuryinjuryinin
flexionflexion--extensionextensionulnoulno--radialradial duxionduxionpro pro -- supinationsupination
or or combinedcombinedwithwith strong strong velocityvelocity and powerand power
Wrist injuriesWrist injuriesDinamicDinamic: : sprainsprain--fracturfractur
Hyperextension injury
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Wrist injuriesWrist injuriesPhysicalPhysical examinationexamination
SwellingSwelling
EmatomiEmatomi
Compare Compare withwith the the wholewhole sideside
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Wrist injuriesWrist injuriesDiagnosticDiagnostic problemproblem
EasyEasyin in seriousserious and and obviousobvious
pathologyspathologys
DifficultDifficult
in in hiddenhidden pathologyspathologys
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Wrist injuriesWrist injuriesPhysicalPhysical examinationexamination
activactiv movementmovementFlexionFlexion and and extensionextension ulnoulno--radiale radiale duxionduxion
Wrist injuriesWrist injuriesPhysicalPhysical examinationexamination
activactiv movementmovementpronoprono--supinazionsupinazion
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Wrist injuriesWrist injuriesfindfind the the painfullpainfull pointpoint
RoentgenographicRoentgenographic approachapproach
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RoentgenographicRoentgenographic approachapproachStandard Standard posteroanteriorposteroanterior viewview (PA)(PA)
Linee di Gilula
RoentgenographicRoentgenographic approachapproachStandard Standard laterallateral viewview
R
L
C
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FurtherFurther instrumentalinstrumental esaminationesamination
ArthrographyArthrography (mono, bi or (mono, bi or tricompartimentaltricompartimental))ConventionalConventional tomographytomography (CT) and (CT) and CTCT--arthrogaphyarthrogaphyMagneticMagnetic resonanceresonance imagingimaging (MRI)(MRI)UltrasoundUltrasoundArthroscopyArthroscopy
InstrumentalInstrumental examinationexamination specificspecificvorvor bone bone tissuetissue
RadiographyRadiography
CTCT
MRIMRI
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InstrumentalInstrumental examinationexamination specificspecificvorvor ligamentligament
IndirectIndirect
-- ArthrogrgaphyArthrogrgaphy-- ArthroArthro CTCT-- ArhtroArhtro MRIMRI
DirectDirect
-- MRI MRI
-- ArthroscopyArthroscopy
Most frequently Injuries of the WristMost frequently Injuries of the Wrist
Bone InjuriesBone Injuries
-- Carpal Scaphoid FractureCarpal Scaphoid Fracture-- Distal Radius FractureDistal Radius Fracture-- Hook of Hamate FractureHook of Hamate Fracture-- Lunate FractureLunate Fracture
Ligament InjuriesLigament Injuries
-- Scapho Lunate RuptureScapho Lunate Rupture-- Luno Triquetral RuptureLuno Triquetral Rupture-- Midcarpal InstabilityMidcarpal Instability-- Dislocation af the Dislocation af the carpuscarpus-- PerilunatePerilunate dislocationdislocation-- Distal Radioulnar Joint and Distal Radioulnar Joint and
TriangularTriangular FibroFibro--cartilage cartilage ComplexComplex
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Carpal Scaphoid Carpal Scaphoid FratureFrature (CSF)(CSF)
-- The most commonThe most common, 70% of , 70% of allall carpal carpal fracturesfractures
-- The most The most problematicproblematic--in the Diagnosisin the Diagnosis--in the in the TraetamentTraetament
Carpal Scaphoid Bone Carpal Scaphoid Bone FracturFracturBiomechanicBiomechanic
lunatum
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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureBiomechanicBiomechanic
Trauma in more then 90 degrees of Hyperextensionand 10 d. of radial Deviation
Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosis: Diagnosis: PhysicalPhysical ExaminationExamination
-- TendernessTenderness in the in the ““anatomicanatomic snuffboxsnuffbox””
-- DecreasedDecreased rangerange of of motionmotion
-- PainPain withwith dorsiflexiondorsiflexion-- ((SwellingSwelling))
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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosis: Diagnosis: conventionalconventional radiologyradiology
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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosis: Diagnosis: conventionalconventional radiologyradiology
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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosis: Diagnosis: ConventionalConventional radiologyradiology
MONTHS LATERMONTHS LATER
NON UNIONNON UNION
Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiganosisDiganosis: CT: CT
Scaphoid Bone Fractur: NON UNION (PSEUDOARTHROSIS)
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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureClassificationClassification
Herbert’sclassification
Classic
HO = horizontal fractureT = transversal fractureVO = vertical frcture
Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureDiagnosisDiagnosis
AnyAny contactcontact--sport sport athleteathlete whowho asas radialradialwristwrist painpain shouldshould bebe consideredconsidered to to havehave a a
scaphoid fracturescaphoid fracture untiluntil provenproven otherweiseotherweise
In In casescases of of clinicalclinical suspicionsuspicionMRI MRI studiesstudies isis neceserynecesery
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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureTreatmentTreatment
IfIf thethe fracturefracture are are stablestable-- Cast Cast untiluntil healedhealed : 3 : 3 monthmonth-- Cast plus Cast plus useuse of a of a playinplayin cast/cast/splintsplint-- OperationOperation withwith internalinternal fixationfixation
IfIf the the fracturefracture are are instableinstable-- OperationOperation withwith internalinternal fixetionfixetion
Carpal Scaphoid Bone FractureCarpal Scaphoid Bone FractureTreatment Treatment vorvor profesionalprofesional athleteathlete
Open Open reductionreduction and and and and internalinternal fixationfixation
AdvantageAdvantageRiturnRiturn to sport after 6 to sport after 6 weeksweeks ((withwith cast 10cast 10--12 w)12 w)
LessLess rate of rate of nonunionnonunion
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Carpal Scaphoid Bone FractureCarpal Scaphoid Bone Fractureideal ideal treatementtreatement
After 8 weeks
Ligament Ligament injuryinjuryThe most common and mostThe most common and most
problematicproblematic
ScapholunateScapholunateinjuriesinjuries
LunotriquetralLunotriquetral injuries injuries ScafotriquetralScafotriquetral injuryinjuryMidcarpal instabilityMidcarpal instabilityDislocation of the carpusDislocation of the carpus
Distal radioulnar Distal radioulnar joint (DRG) and joint (DRG) and triangulartriangularfibrocartilagefibrocartilagecomplex injuriescomplex injuries(TFC)(TFC)
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ScapholunateScapholunate ruptureruptureDinamicDinamic
Hyperextension traumaand ulnoradial load
ScapholunateligamentScapholunateligament ruptureruptureDiagnosis: Diagnosis: PhysicalPhysical examinationexamination
-- TendernessTenderness of of scafolunatescafolunateareaarea
-- DecreasedDecreased rangerange of of motionmotion
-- ((SwellingSwelling))-- Positive Watson TestPositive Watson Test
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ScapholunateScapholunate ruptureruptureDiagnosis: Diagnosis: physicalphysical examinationexamination
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Verticalizzazione dell’osso navicolare Watson Test
SccapholunateSccapholunate rupture: rupture: DiagnosisDiagnosisconventionalconventional radiologyradiology
Distance > 6mm
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ScapholunateScapholunate rupture: rupture: Diagnosis Diagnosis ArthrographyArthrography ((indirectindirect evaluationevaluation))
ScapholunateScapholunate rupture: rupture: DiagnosisDiagnosisCTCT--arthrographyarthrography ((indirectindirect evaluationevaluation))
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ScapholunateScapholunate rupture: Diagnosisrupture: DiagnosisRMRM--artrhographieartrhographie
( ( indirectindirect and direct)and direct)
Ecogradiente (evidenzia il contrasto) T1 (dettagli anatomici)
ScapholunateScapholunate rupture: Diagnosisrupture: DiagnosisArthroscopyArthroscopy (direct (direct evaluationevaluation))
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acuteacute ScapholunateScapholunate rupture: rupture: TreatmentTreatment
CompleteCompleteopen open ripairripair withwithaugmentetionaugmentetion usingusing a a portionportion of of scafotriquetralscafotriquetralligamentligament
IncompleteIncompletearthroscopycarthroscopyc shrinkageshrinkage
ScafolunateScafolunate rupture acute rupture acute withwith bone bone detachdetach
TreatementTreatement: : operationoperation
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chronicchronic ScapholunateScapholunate rupturerupturetreatementtreatement
RecontructionRecontruction of Sof S--L ligamentL ligament-- bonebone--ligamentligament--bonebone ((oteoligamentoplasticoteoligamentoplastic))-- transosstransossäärere fiationfiation withwith ligament ligament augmentationaugmentation
BatBat: 1) long : 1) long athleticathletic activityactivity interruptioninterruption2) bad 2) bad prognosisprognosis3) 3) riskrisk to to interruptinterrupt the the athleticathletic activityactivity
CronicCronic scapholunatescapholunate rupture: rupture: BoneBone--ligamentligament--bonebone repairrepair
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CronicCronic scapholunatescapholunateLigament Ligament fixationfixation ((TaleisnikTaleisnik))
ScapholunateScapholunate repairrepair::RisultRisult
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TriangularTriangular fibrocartilagefibrocartilage (TFC)(TFC)
TFCTFCStabilizerStabilizer of distalof distal
radioulnar joint radioulnar joint (DRUJ)(DRUJ)
DRUJ
TFC TFC anatomyanatomyulnotriquetralulnotriquetral and and ulnoamateulnoamate ligamentligament
Ulnolunate ligament
Ulnotriquetral ligament
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TFC TFC anatomyanatomy: : dordsaldordsal and and palmarpalmar ligamentligament
Dorsal radioulnar ligament
Palmar radioulnar ligament
TFC TFC anatomyanatomy::ECU ECU compartementcompartement
ECU
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TFC TFC injuryinjury
Acute Acute traumatictraumatic eventsevents involveinvolve axialaxial loadload--bearingbearing withwith rotationalrotational stressstress
OveruseOveruse
RepetitiveRepetitive traumatrauma
TFC TFC injuryinjuryDiagnosisDiagnosis
AnamnesisAnamnesisDifferentilalDifferentilal diagnosisdiagnosisPhysicalPhysical examinationexaminationImagingImaging studiesstudiesArthroscopyArthroscopy
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TFC injuriesTFC injuriesDianosisDianosis: : physicalphysical examinationexamination
TendernessTenderness betweenbetween the the pisiformpisiform and and ulnarulnar stiloidstiloidon the on the ulnarborderulnarborder of the of the wristwristDistal radio Distal radio ulnarulnar joint joint instability (piano instability (piano keykeysignsign))
TFC injuriesTFC injuriesDiagnosis: Diagnosis: imagingimaging studiesstudies
TricompartimentTricompartiment Wrist Wrist arthrogramarthrogramMRI MRI arthrogramarthrogram (high (high resolutionresolution))CT CT scanscan in in neutralneutral and and pronationpronation and and supinationsupinationWrist Wrist arthroscopyarthroscopy
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TFC InjuriesTFC InjuriesDiagnosis: Diagnosis: arthroscopyarthroscopy
AdvantageAdvantage-- DiagnosticDiagnostic-- TherapeuticTherapeutic
TFC injuriesTFC injuriesDiagnosis andDiagnosis and TreatementTreatement
The The physicianphysician treatingtreating high high levellevel athletesathletes maymayconsiderconsider a a more more aggressivaggressiv approachapproach to the to the patientpatient withwith suspectedsuspected TFC/DRUJ TFC/DRUJ injuryinjury
1)1) IfIf DRUJ DRUJ intabilityintability isis demonstrateddemonstrated, , earlyearlyinterventionintervention withwith arthroscopyarthroscopy (TFC (TFC repairrepair))
2)2) IfIf DRUJ DRUJ isis stablestable and and symtomssymtoms are are presentpresentforfor 2 2 weeksweeks, , arthroscopyarthroscopy isis indicatedindicated
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TFC injuries TFC injuries acuteacuteArtrscopicArtrscopic diagnosis diagnosis
CLASSIFICATION OF TFCC TEARS (CLASSIFICATION OF TFCC TEARS (PalmerPalmer))
1A ( 1A ( traumatictraumatic tearstears of the of the centralcentral articulararticular disc)disc)1B (1B (peripheralperipheral TFC at the TFC at the ulnarulnar insertioninsertion) ) 1C (distal to 1C (distal to ulnolunateulnolunate--ulnotriquetralulnotriquetral liglig.).)
1D (1D (lesionlesion at the at the radialradial insertioninsertion))
TFC injuries acuteTFC injuries acutePalmerPalmer 1A1A
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TFC injuries acuteTFC injuries acutePalmerPalmer 1B1B
TFC injuries acuteTFC injuries acutePalmerPalmer 1C1C
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TFC injuries acuteTFC injuries acutePalmerPalmer 1D1D
TFC acute injuriesTFC acute injuriesTreatementTreatement
PalmerPalmer 1A: 1A: arthroscopicarthroscopic debridementdebridementPalmerPalmer 1B: 1B: artroscopicartroscopic repairrepairPalmerPalmer 1C: 1C: repairrepair of of ulnocarpalulnocarpal ligamentsligaments open open or or arthroscopicalyarthroscopicalyPalmerPalmer 1D: 1D: arthroscopicarthroscopic repairrepair (?)(?)
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LunotriquetralLunotriquetral injuriesinjuriesDinamicDinamic
Extension trauma and radial devation
Lunotriquetral ligament
PhysicalPhysical examinationexaminationlunoluno--triquetral instability(LT)triquetral instability(LT)
Lunotriquetral ballottement(Reagan’s)
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LunotriquetralLunotriquetral injuriesinjuriesDiagnosisDiagnosis
UlnarsidedUlnarsided wrist wrist painpainWeaknessWeaknessGiwingGiwing waywayClick Click soundsoundTendernessTenderness over the over the lunotriquetrallunotriquetral ligamentligamentLunotriquetralLunotriquetral shearshear test test positivpositiv
LunotriquetralLunotriquetral injuriesinjuriesDiagnosis Diagnosis
Arthrography (?)Arthrography (?)MagneticMagnetic resonanzresonanzMost Most definitivediagnosticdefinitivediagnostictooltool are the are the arthroscopyarthroscopy
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LunotriquetralLunotriquetral injuriesinjuriesTherapyTherapy
AcuteAcute
immobilisationimmobilisation((HealingHealing in 80% of in 80% of casescases) )
CronicCronic:: surgicalsurgical optionoption
-- arthroscopicarthroscopiclunotriquetrallunotriquetral ligament ligament debridementdebridement
-- lunotriquetrallunotriquetral ligament ligament augmentationaugmentation plasticplastic
-- lunotriquetrallunotriquetral arthrodesisarthrodesis
PerilunatePerilunate dislocationdislocation
-- SignificantSignificant traumatrauma-- SignificantSignificant swellingswelling and and
decreaseddecreased ragerage of of motionmotion
-- ExcessiveExcessive radiocarpalradiocarpalhyperextensionhyperextension and and ulnarulnarddeviationddeviation plus plus intercarpal intercarpal supinationsupination
Disruption of ligament:- Scapholunate- Lunotriquetral- Capitolunate volar
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PerilunatePerilunate dislocationdislocationDiagnosisDiagnosis
PerilunatePerilunate dislocationdislocationDiagnosisDiagnosis
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PerilunatePerilunate dislocationdislocationTreatementTreatement: : surgerysurgery
PerilunatePerilunate dislocationdislocationResultResult
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Hook of the HamateHook of the Hamate FracturreFracturre
IncidenceIncidence 2%2%--4% 4% aallaallccarpalccarpal fracturesfracturesDirect trauma (Direct trauma (bybyabutementabutement of the hook of the hook on on anan object )object )TendernessTenderness over the over the hookhookDiagnosis:Diagnosis:--conventionalconventional radiologyradiology--CT CT scanscan
Lunate FractureLunate Fracture
isis rarerareadequateadequate traumatraumatendernesstenderness of the lunateof the lunateIn In combinationcombination withwithavascularavascular necrosisnecrosis((KienbKienböökk))Diagnosis:Diagnosis:-- conventopnalconventopnal radiologyradiology-- CT CT
Dinamic with hyperextension traumaand ulnar load
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Lunate Lunate fracturesfracturesDiagnosisDiagnosis
Lunate fractureLunate fractureTreatementTreatement
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LunatumLunatum FractureFractureResultResult
Grazie mille perGrazie mille per ll’’ascoltoascolto
MD G. RigoniVia St. Anna cp 16CH-6924 Sorengo